Australian Prescriber - Emergency management of anaphylaxis in the community



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Emergency management of anaphylaxis in the community

(Aust Prescr 2007;30:115)

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Emergency management of anaphylaxis
in the community

Recognise clinical features
Early	Progressive	Severe
sensations of warmth, itching especially in axillae and groins feelings of anxiety or panic	erythematous or urticarial rash oedema of face, neck, soft tissues abdominal pain and vomiting dyspnoea	hypotension (shock) bronchospasm (wheezing) laryngeal oedema (stridor, aphonia, drooling) arrhythmias, cardiac arrest hypoxaemia, cyanosis
Note: Severe clinical features may appear extremely rapidly without prodromal features

Acute management

Anaphylaxis is a life-threatening emergency
Use the ABC of resuscitation (Airway, Breathing and Circulation)
IF WORKING ALONE, CALL FOR ASSISTANCE

Remove allergen
Stop any suspected medication or diagnostic contrast material, remove allergen from patient's mouth, scrape out bee stings.

Give oxygen
Lie patient flat and give oxygen by face mask at the highest possible flow rate (> 6 L/minute).

Give adrenaline
Immediately inject adrenaline 1:1000 intramuscularly in the lateral thigh.

Adults (and children > 25 kg)	Children (< 25 kg)	(use 1 mL/insulin syringe)

< 50 kg . . . . . . . . . . . give 0.25-0.50 mL	1 year . . . . . . . . . . . 10 kg . . . . . . . . . give 0.1 mL
> 50 kg . . . . . . . . . . . . . . . give 0.50 mL	3 years . . . . . . . . . . 15 kg . . . . . . . . give 0.15 mL
	5 years . . . . . . . . . . 20 kg . . . . . . . . . give 0.2 mL
(See Notes 1, 2)	8 years . . . . . . . . . . 25 kg . . . . . . . . give 0.25 mL

Start rapid fluid resuscitation
Establish an intravenous line and infuse normal saline or Hartmann's solution (20 mL/kg). Continue as necessary.

Give further adrenaline
If necessary, repeat intramuscular dose every 5 minutes. Large doses of adrenaline may be needed, up to a maximum of 5 mL (5 mg). If the patient remains shocked after two intramuscular doses, consider an adrenaline infusion to restore blood pressure. (See Notes 3, 4)

Ventilate
If there is severe respiratory and circulatory collapse or coma, ventilate the patient. (See Note 5)

Additional measures

Bronchodilators . . . . . . . . . . . . . . . . .	For bronchospasm, give salbutamol or terbutaline by nebuliser, or aerosol with spacer device. In severe cases use continuously.
Corticosteroids . . . . . . . . . . . . . . . . . .	Give hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg intravenously. (See Note 6)
Nebulised adrenaline (5 mL of 1:1000). .	May be tried in laryngeal oedema and may ease upper airway obstruction. However, do not delay intubation if upper airway obstruction is progressive.

Supportive treatment
Observe vital signs frequently and, if possible, monitor electrocardiogram and pulse oximetry.
Keep patient in hospital for observation for at least 4-6 hours after the complete resolution of abnormal symptoms and signs, as biphasic reactions may occur. (See Note 7)

Notes

Adrenaline is life-saving and must be used promptly. Withholding adrenaline due to misplaced concerns of possible adverse effects can result in deterioration and death of the patient. It is safe and effective.
Adrenaline 1:1000 contains 1000 microgram in 1 mL (1 mg/mL). The volumes of adrenaline recommended for adults and children approximate to 5-10 microgram/kg. Children's weights are approximate for age.
If critical care facilities are not immediately available, give the following adrenaline infusion:

• Mix 1 mg adrenaline (1 ampoule) in 1000 mL of normal saline
• Start infusion at 5 mL/kg/hour (approx. 0.1 microgram/kg/minute)
• Titrate rate up or down according to response.

Some cases are resistant to adrenaline, especially if the patient is taking beta blocking drugs. If adequate doses of adrenaline are not improving the situation, give glucagon 1-2 mg intravenously over 5 minutes.
Drug-assisted intubation for impending airway obstruction is a very high-risk procedure and should only be attempted by an expert.
Corticosteroids may modify the overall duration of a reaction and may prevent relapse. However, onset of action will be delayed. Never use these to the exclusion of adrenaline.
Keep patient in hospital longer if there is a history of asthma or previous allergy, or if the patient needed repeated doses of adrenaline. All patients must be followed up to investigate possible provoking factors and for further management.

Published as an insert to Australian Prescriber 2007, Vol.30No.5.

Endorsed by the Australasian College for Emergency Medicine, the Australasian Society of Clinical Immunology and Allergy, the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Physicians (adult and paediatric divisions), and the Royal Australian and New Zealand College of Radiologists.